Coding to Specificity Changes with SummaCare

Since the implementation of ICD-10, SummaCare has not denied claims based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the correct family.

Effective June 1, 2017, SummaCare will begin rejecting claims that are not coded to the highest level of specificity. The ICD-10 code set allows clinicians to more precisely describe diseases and conditions than they could before.

CMS instituted the 1-year grace period to help physicians get up to speed on correct diagnostic coding. SummaCare followed this rule and also allowed the grace period. However, SummaCare will begin rejecting claims on June 1, 2017 if a specific ICD-10 diagnosis code is not submitted.

Please Note: This rejection is not based on date of service, but is based on the date the claim is submitted.

To avoid payment delays, please make sure your billing and coding departments are aware of this requirement.